Prosthetic heart valve with collapsible holder

ABSTRACT

A prosthetic heart valve holder system includes a prosthetic heart valve having a base at an inflow end, a plurality of commissure posts extending from the base toward an outflow end, and valve leaflets secured to the commissure posts to permit flow through the heart valve. A deflector is provided at the outflow end having a central hub and a plurality of arms extending from the central hub secured to and covering the tips of respective commissure posts. A valve support body is secured to the base and a post connects the valve support body to the hub of the deflector. The plurality of arms are sufficiently collapsible such that, in a first position, free ends of the arms are located axially between the hub and the valve support body to prevent suture looping during an implant procedure, and in a second position, the hub is located axially between the free ends of the arms and the valve support body to permit removal of the deflector from the outflow side of the valve, through the valve leaflets, to the inflow side of the valve.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.15/963,311, filed Apr. 26, 2018, now U.S. Pat. No. 107,993,353, whichclaims the benefit of U.S. Application No. 62/491,998, filed Apr. 28,2017, the entire contents all of which incorporated by reference hereinfor all purposes.

BACKGROUND Field

The present disclosure generally concerns medical devices, deploymentmechanisms, and methods for deploying such medical devices. Morespecifically, the disclosure relates to surgical replacement of heartvalves that have malformations and/or dysfunctions. Embodiments of theinvention relate to holders for facilitating the implantation ofprosthetic heart valves at such native heart valves sites, for example,for a mitral valve replacement procedure. Embodiments of the inventionalso relate to methods of using the holders to facilitate implantationof prosthetic heart valves.

Description of Related Art

Referring first to FIG. 1, the human heart is generally separated intofour pumping chambers which pump blood through the body. Each chamber isprovided with its own one-way exit valve. The left atrium receivesoxygenated blood from the lungs and advances the oxygenated blood to theleft ventricle through the mitral (or bicuspid) valve. The leftventricle collects the oxygenated blood from the left atrium and pushesit through the aortic valve to the aorta, where the oxygenated blood isthen distributed to the rest of the body. Deoxygenated blood from thebody is then collected at the right atrium and advanced to the rightventricle through the tricuspid valve. The right ventricle then advancesthe deoxygenated blood through the pulmonary valve and the pulmonaryartery to the lungs to again supply the blood with oxygen.

Each of the valves associated with the chambers of the heart are one-wayvalves that have leaflets to control the directional flow of the bloodthrough the heart, and to prevent backflow of the blood into otherchambers or blood vessels that are upstream of the particular chamber.The valves are each supported by an annulus having a dense fibrous ringattached either directly or indirectly to the atrial or ventricularmuscle fibers. When a valve become diseased or damaged, leakage orregurgitation may occur, where some of the blood travels back upstreamthrough the diseased or damaged valve, and the efficiency and/or generalfunctionality of the heart may be compromised.

Various surgical techniques can be performed to repair or replace adiseased or damaged valve. In some valve replacement procedures, theleaflets of the diseased or damaged native valve are first removed toprepare the valve annulus for receiving the prosthetic valve. FIG. 2shows an example of one type of popular prosthetic valve 1 that is atissue-type bioprosthetic valve generally constructed withnatural-tissue valve leaflets 2, made for example, from porcine tissueor bovine pericardium, or from artificially synthesized tissue, that aremounted on a surrounding valve stent structure 3. The shape andstructure of the leaflets 2 are supported by a number of commissureposts 4 positioned circumferentially around the valve stent structure 3.In these valves, a biocompatible cloth-covered suture or sewing ring 5can also be provided on an inflow end of the stent structure 3 of thevalve 1, for attachment to the native valve annulus. Such prostheticvalves function much like natural human heart valves, where the leafletscoapt against one another to effect the one-way flow of blood.

When implanting a tissue type prosthetic valve as described above at anative valve annulus, a number of sutures may be involved in theattachment process, many of which may be pre-installed for providing atrack on which the valve is advanced along, or “parachuted” down, untilit is properly positioned at the implant site. Additional attachmentsutures may also be applied between the prosthetic valve and the heartwalls after proper placement, to securely attach or hold the valveimplant in place. Meanwhile, in some cases, the prosthetic valves areimplanted through small access channels using one of various minimallyinvasive surgical procedures, where visibility at the implant site maybe impeded or obstructed. In addition, depending on the direction ofimplantation, for example, with some mitral valve replacementprocedures, commissure posts of the stent or frame, or other portions ofthe prosthetic valve may be pointed distally and located on a blind sideof the valve.

Each of the above factors may lead to tangling of the pre-installedsutures with the valve prosthesis, most commonly with the commissureposts of the frame, since they provide a protrusion on which the suturescan easily loop around and tangle. This type of entanglement of sutureswith prosthetic valves is referred to as “suture looping,” whichspecifically refers to instances where a pre-installed suture isinadvertently wrapped around one or more of the commissure post tips,where it can then migrate towards and damage the leaflets or interferewith proper leaflet coaptation or other valve operation when the suturesare tightened or secured, resulting in improper valve operation. In somecases, such tangling may not be apparent to the practitioner at the timeof implantation, and will only be revealed some time later when valveoperation is observed to be improper or other complications arise in thepatient, in which case, it may be necessary to initiate anotherprocedure to repair or replace the prosthetic valve.

SUMMARY

Attempts have been made to resolve the problem of suture looping, someof which revolve around the holders which hold the prosthetic valveswhen they are delivered to the native valve annulus. In one example, aholder has a mechanism that urges the commissure posts of the prostheticvalve radially inward during delivery, so that the ends of thecommissure posts are pointed inwards, to reduce the possibility ofsutures catching against or looping around them. After the valveprosthesis is delivered to the implant site, the holder is removed,releasing and expanding the commissure posts to their originalpositions. However, although the commissure posts are biased inwardlyduring delivery, since the ends of the commissure posts remain free,these holders have not been fully effective in eliminating instances ofsuture looping.

Meanwhile, Edwards Lifesciences has developed another valve holdersystem, known as Tricentrix®, specifically for use in mitral valvereplacement procedures to protect the valve from suture looping duringvalve implantation. The system includes monofilament deflection suturesthat attach to both the holder and pairs of commissures of theprosthetic valve, so that the sutures run across the outflow end of thevalve between the ends of the commissures. When the holder is actuated,a central post extends distally through the prosthetic valve between theleaflets and pushes against the sutures in the middle of the valvebetween the commissures, pushing the sutures distally and causing anangled tent-like or umbrella shape of sutures. The pressure on thesutures deflects the commissures slightly inward, while also forming theangled umbrella shape of the sutures that slope outwardly and downwardlyfrom the central post to the commissure posts. These angled surfacesdeflect away from the prosthetic valve any other sutures, such as thepre-installed attachment sutures, mentioned above, that might otherwiseengage and be looped around a commissure or valve leaflet.

Other holders have also been developed in an attempt to further reduceinstances of suture looping. However, some of these holders are verycomplex, for example, incorporating various rotary and advancementmechanisms in addition to the original hold and release mechanisms, suchthat a number of additional steps must be taken by the practitioner tooperate the holders correctly. Many of these holders have proven to betoo complicated and/or prone to user error, such as a failure to executeall deployment steps in the correct order. Consequently, whenpractitioners use these holders improperly, suture looping can stilloccur, while the implant process may also be further complicated byissues arising from user error.

In addition to the above, many of the newer holder designs alsoincorporate many additional parts that interact with one another or thatmust be assembled by the practitioner or other end user, which may alsolead to additional complications. For example, where additional partsmust be threaded into one another, cross-threading can occur when thethreads of the various parts are inadvertently misaligned. This and/orother interactions between the additional parts may lead to increasedpossibility of the holder being damaged or breaking, and of loosefragments being generated.

Features of the invention provide for new holder systems and methods ofusing the holder systems, which reduce or eliminate the occurrence ofsuture looping or other damage to the prosthetic valves duringimplantation. Operation of the holders is also simplified, where theadditional features of the holders can be pre-deployed or integrated fordeployment or actuation automatically when performing existing stepsalready well-known by users, thereby reducing or eliminating mistakescaused by user error and increasing patient safety. The holders can alsohave a reduced number of parts and/or provide for integrated alignmentfeatures or other safety features, so that cross-threading or otherdamaging interactions between parts can also be prevented. These holderscan also be made at similar or reduced costs compared to existingholders. In addition, reducing the number of deployment steps reducesthe time to complete the surgical procedure, and reduces the complexityof training, or retraining, needed to learn the procedure.

In one embodiment of the invention, a prosthetic heart valve holdersystem includes a prosthetic heart valve having an inflow end and anoutflow end and a flow axis therethrough. The heart valve further has abase at the inflow end, a plurality of commissure posts extending fromthe base toward the outflow end and circumferentially spaced around theflow axis, and valve leaflets secured to the commissure posts to permitflow through the heart valve, each commissure post having a tip at theoutflow end. The valve holder system further includes a deflector at theoutflow end having a central hub and a plurality of arms extending fromthe central hub. A first end of each of the arms are secured to thecentral hub and a second end of each of the arms are secured to andcover a tip of a respective commissure post of the plurality ofcommissure posts. A valve support body is secured to the base at theinflow end and a post extends from the valve support body at the inflowend of the heart valve, through the valve leaflets, to the hub of thedeflector at the outflow end. The plurality of arms of the deflector aresufficiently collapsible such that, in a first position, the second endof each of the plurality of arms is located axially between the hub andthe valve support body such that the deflector prevents suture loopingduring an implant procedure. In a second position, the hub is locatedaxially between the second end of each of the plurality of arms of thedeflector and the valve support body to permit removal of the deflectorfrom the outflow side of the valve, through the valve leaflets, to theinflow side of the valve without damaging the valve leaflets afterdetachment of the deflector arms from the tips of the commissures.

In a preferred embodiment of the prosthetic heart valve system, theplurality of commissures posts is at least three commissure posts andthe plurality of arms of the deflector is at least three arms. In otherembodiments, the post is a solid pin and the post may be molded orpress-fit to the deflector. In a further embodiment, the deflector andthe valve support may be permanently fixed a first distance apart fromone another by the post. The prosthetic heart valve, the deflector andthe valve support body may also be mounted in a package in the firstposition.

In a further preferred embodiment of the invention, the deflector is amonolithic body of flexible material. The flexible material preferablyhas a durometer in the range of Shore A30 to Shore A70. In analternative embodiment, each of the plurality of arms has a transverselyextending notch that forms a living hinge. In other embodiments, a layerof material that is resistant to viscoelastic stress relaxation, such asa layer of cloth, is embedded in or overmolded to the arms of thedeflector. Preferably the plurality of arms of the deflector are heldtaut between the central hub and the plurality of commissure posts. Inanother embodiment, the second end of each arm is a channel member thatextends over the top and three sides of the tip of the respectivecommissure post.

In a further embodiment, the prosthetic heart valve holder systemincludes an adaptor configured to be detachably connected to the valvesupport body on an opposite side of the valve support body from thedeflector. The adaptor can be detachably connected to the valve supportbody by a suture.

A plurality of additional sutures can be routed from the opposite sideof the valve support body, through respective commissure posts to thetips of the commissure posts, through respective deflector arms, back tothe tips and back down the commissure posts, through the valve supportbody again and fixed to the opposite side of the valve support body. Ina preferred embodiment, each of the plurality of additional sutures hasa portion that is placed over a gap on the opposite side of the valvesupport body to permit the portions to be all cut in a single action.The adaptor may include a suture shield mounted over the gap to protectthe suture portions from premature cutting until the adapter is detachedfrom the valve support body. A handle may also be detachably connectableto the adaptor from the opposite side of the valve support body from thedeflector.

In another alternative embodiment, a prosthetic heart valve holderincludes a deflector having a central hub and a plurality of armsextending from the central hub, each of the plurality of arms having afirst end secured to the central hub and a free second end radiallyoutward from the hub, the valve holder further includes a valve supportbody and a post extending from the valve support body to the hub of thedeflector. The plurality of arms of the deflector are sufficientlycollapsible such that, in a first position, the second end of each ofthe plurality of arms is located axially between the hub and the valvesupport body, and in a second position, the hub is located axiallybetween the second end of each of the plurality of arms of the deflectorand the valve support body.

In a further embodiment, the plurality of arms of the deflector aresufficiently collapsible such that, in a first position, the hub is afirst axial distance from the valve support body and the second end ofeach of the plurality of arms extends an axial distance less than thefirst axial distance from the valve support body and in a secondposition, the second end of each of the plurality of arms of thedeflector is at an axial distance greater than the first axial distance.

According to embodiments of the invention, holders for prosthetic valvedelivery reduce or eliminate occurrences of suture looping and/or otherdamage to the valves when the valves are implanted, while the mechanismsfor deploying these features are integrated into the holders in a waythat make it easier for end users to use and deploy.

BRIEF DESCRIPTION OF THE DRAWINGS

Further features and advantages of the invention will become apparentfrom the description of embodiments using the accompanying drawings. Inthe drawings:

FIG. 1 shows a schematic cross-sectional view of a human heart;

FIG. 2 shows a schematic perspective view of an example of a prostheticvalve that can be used with embodiments of the invention;

FIG. 3 shows an exploded perspective view of a valve holder, adapter andhandle for a prosthetic heart valve according to an embodiment of theinvention;

FIG. 4 shows a top perspective view of the valve holder, adapter andhandle of FIG. 3 in an assembled state;

FIG. 5 shows a bottom perspective view of the valve holder and adapterof FIG. 3 in the assembled state;

FIG. 6 shows a perspective view of the valve holder of FIG. 3 with aprosthetic heart valve;

FIG. 7 shows a top perspective view of a deflector of the valve holderof FIG. 3;

FIG. 8 shows a bottom perspective view of the deflector of FIG. 3;

FIG. 9 shows a top perspective view of a valve support body of the valveholder of FIG. 3;

FIG. 10 shows a bottom perspective view of the valve support body ofFIG. 3;

FIG. 11 shows a bottom perspective view of an adapter of the valveholder of FIG. 3;

FIG. 12 shows a top perspective view of the adapter of FIG. 3;

FIG. 13 shows a cross-sectional view of the adapter of FIG. 12;

FIG. 14 shows a bottom perspective view of the valve support body ofFIG. 3 with sutures;

FIG. 15 shows a perspective view of the valve holder and prostheticheart valve of FIG. 3 with the deflector in a collapsed state;

FIG. 16 shows a perspective view of a deflector and a prosthetic heartvalve according to a modified embodiment of the invention;

FIG. 17 shows a perspective view of a deflector and a prosthetic heartvalve according to a further modified embodiment of the invention;

FIG. 18 shows a perspective view of the deflector and prosthetic heartvalve of FIG. 17 with the deflector in a partially collapsed state andthe valve leaflets removed to better view the other parts;

FIG. 19 shows a perspective view of a deflector according to a modifiedembodiment of the invention;

FIG. 20 shows a perspective view of a deflector, a handle adapter and aprosthetic heart valve according to an alternative embodiment of theinvention;

FIG. 21 shows a perspective view of a deflector, an adapter, and aprosthetic heart valve mounted to a ring according to anotheralternative embodiment of the invention.

DETAILED DESCRIPTION

Disclosed herein are various valve holders for assisting in the deliveryand implantation of prosthetic heart valves at an implant site, andmethods for preparing the prosthetic heart valves for such procedures.Embodiments of the valve holders reduce occurrences of variouscomplications that may arise during implantation, while remaining simplefor end users to use. By providing these improved valve holders, damageto the prosthetic valves during surgical procedures can be reduced, andadditional costs for extended or additional procedures and replacementvalves can be avoided.

The valve holders disclosed herein are particularly useful for avoidingsuture looping and other valve damage during advancement of theprosthetic valves to the implant sites as well as during final suturingof the valves at the native valve annulus. In procedures wherecommissure posts of the prosthetic valve point distally, for example, inmany mitral valve replacement procedures, the commissure posts point inthe direction of valve advancement and may be more prone to suturelooping or other entangling. In these cases, valve holders according toembodiments of the invention provide deflectors that deflect thepre-installed sutures away from the prosthetic valve. In someembodiments, the valve holder system has a deflector that ispre-deployed without requiring any action by the surgeon or operatingroom staff and is ready for delivery to the native valve annulus uponremoval of the packaging. Upon securement of the prosthetic heart valveto the annulus, the deflector is collapsible to permit it to be pulledthrough the leaflets without causing any damage when the holder isremoved from the prosthetic valve. In other embodiments, the surgeon oroperating room staff may effect automatic deployment or actuation of therespective valve holders to their deployed positions, using steps thatare already associated with handling of existing valve holders. As withthe pre-deployed system, upon securement of the prosthetic heart valveto the native valve annulus, the deflector is collapsible to permit itto be pulled through the leaflets without causing any damage when theholder is removed from the prosthetic valve. In this fashion, ease ofuse of the below described valve holders can be maintained, while usererror can be minimized.

With reference to FIGS. 3-6, an embodiment of the prosthetic valveholder system of the present invention includes a valve holder 100 thatincludes a valve support body 110 attached to a deflector 112 by acentral post 114, an adapter 116, an optional handle 118, and aprosthetic heart valve 1. According to an embodiment of the invention,the prosthetic heart valve holder system is provided to the surgicalteam in a pre-deployed arrangement with the prosthetic valve 1 capturedbetween the valve support body 110 and the deflector 112, as shown inFIG. 6. The post 114 extends through the center of the prosthetic valvethrough the leaflets 2 and between the support body 110 and thedeflector 112. According to this embodiment, the system does not needany steps to activate the suture looping protection, and can be usedwith or without the handle 118.

With reference to FIGS. 7 and 8, the deflector 112 includes a centralhub 130 and three generally radially extending arms 132. Preferably, thedeflector is a monolithic body made of a highly flexible material whichallows the arms to easily fold when the deflector is pulled through theleaflets of the prosthetic valve after attachment of the valve to thenative valve annulus and during release of the holder.

Preferred materials for the deflector are rubber, such as a softsilicone rubber, a soft flexible polymer, or other materials having adurometer in the range of Shore A30-A70, or preferably about Shore A50.

Additionally, the deflector may be overmolded with a cloth, fabric orother thin mesh material to give the arms strength and resistance toviscoelastic stress relaxation, yet maintain the flexibility of thedeflector to permit removal through the valve leaflets. The cloth,fabric or mesh may be a single piece embedded in the deflector acrossthe central hub and the three arms or may be multiple pieces.

The central hub 130 of the deflector has a smooth convexly curved topsurface 134, a cylindrical side surface 136, and a truncated conicalbottom surface 138 that narrows in a direction away from the topsurface. The curved top surface 134 is for deflecting away from theleaflets any pre-installed attachment sutures during installation of theprosthetic valve. The conical bottom surface 138 provides a taperedsurface to gradually spread the leaflets during retraction and removalof the deflector through the leaflets after the valve has been attached.At the truncated tip of the conical bottom surface, an opening to a bore142 is provided for receipt of one end of the post 114.

Extending radially and downwardly away from the central hub 130 are thethree arms 132. One end of each arm is secured to the cylindrical sidesurface of 136 of the central hub. The other end of each arm isconfigured to mount over a tip 6 of a respective commissure post 4 ofthe prosthetic valve (see FIG. 2). Accordingly, the length of each armshould be sufficient to extend from the central hub to the commissurepost and over the commissure post. Preferably, the arms are held tautbetween the hub and the posts to cause any pre-installed assemblysutures to slide down the deflector during installation of theprosthetic valve, thus preventing suture looping. In addition, the armsmay be used to also deflect or urge the commissure posts inward.

To improve the connection between the arms 132 of the deflector 112 andthe commissure posts 4, the radially outer end portion of each arm formsa channel member 150 that extends down from the end of each arm. Thechannel member 150 has an end wall 152 and two side flanges 154extending radially inward from the end wall to form a channel 156 toreceive a tip 6 of a commissure post 4. The end wall 152 of each channelmember is thickened and includes two suture holes 158 extending throughthe end wall into the channel 156. Preferably, the end wall of thedeflector is wider than the width of the tip of the commissure post andthe side flanges cover a substantial portion of the sides of the tip soas to surround the top and outside of the tip, thereby offeringexcellent protection against suture looping.

To improve the flexibility of the arms of the deflector, the width (w)of each arm, measured across the top surface of the arm, is graduallytapered or narrowed beginning from a location near the channel member150 of the arm to a location near the central hub 130.

With reference to FIG. 9, the valve support body 110 is in the form of acircular disk 170 having a raised central platform 172 that is smallerin diameter than the circular disk 170. The central platform 172 isconcentric to the circular disk and therefore an outer circumferentialportion of the circular disk forms an annular base surface 174 that canreceive and be attached to the suture or sewing ring 5 of the prostheticheart valve (see FIG. 2). The annular base surface 174 is provided withthree pairs of suture holes 175 a, 175 b, 175 c through the valvesupport body, each pair being configured to be aligned with a respectivecommissure post 4 of the prosthetic heart valve in order to suture thevalve 1 to the support body 110.

Projecting up from the raised central platform 172 of the support bodyis a cylindrical base member 176 centrally located on the platform 172.Furthermore, projecting up from the base member 176 is a truncatedconical member 178 having a conical surface that narrows in a directionaway from base member 176. The narrowing will assist in preventing anyinterference between the valve support body 110 and the prosthetic valveleaflets 3 during the surgical procedure. At the truncated tip of theconical member 178, an opening to a bore 180 is provided for receipt ofan end of the post 114 (see FIG. 3).

In one embodiment, the post is molded to the conical member 178 of thesupport body 110 and to the truncated tip of the deflector 112. Othermethods of attachment may be used such as a press fit, but theattachment should be secure to prevent detachment during removal of thevalve support body 110 and deflector 112 from the prosthetic valve aftercompletion of the surgical procedure. In addition, the post has a smalldiameter such that it can pass through a central hole 7 of coaptedleaflets of the valve, without significantly deforming the leaflets.

A beveled surface 182 is located between the central platform 172 andthe base member 176. In an embodiment, a pair of suture holes 184 arelocated next to each other through the beveled surface in order toprovide a securement point for the adapter 116 (see FIG. 3) to thesupport body 110. It will be appreciated that the suture holes 184 maybe placed at other locations of the support body as deemed necessary.Passing through the central platform are also a pair of tool openings186 such that the valve support body 110 can be grasped and positionedas needed by a surgical instrument (not shown). The openings 186 may beof any suitable shape (e.g., rectangular) to provide a rib 188 or otherstructure between the openings for grasping.

With reference to FIG. 10, the bottom side 200 of the valve support body110 includes a central hole 202 to receive the adapter 116 (see FIG. 3).The central hole 202 includes a first axially extending hole portionhaving opposed flat sides 204 and opposed curved sides 206. At the endof the first axially extending hole portion, shoulders 208 are formedthat serve as an abutment to a corresponding portion of the adapter 116.Extending axially further into the valve support body 110 is a secondaxially extending hole portion having a cylindrical inner surface 210.The second axially extending hole portion is also sized to receive acorresponding portion of the adapter, which will be described in moredetail below.

Projecting from the bottom side 200 of the valve support body are aplurality of suture supports 212 a, 212 b and suture tunnels 214 a, 214b, 214 c. The suture supports 212 a, 212 b are rectangular blocks, eachwith an exposed groove surface 216. The groove is a smooth cylinder orotherwise concave surface. In an embodiment of the invention, the suturesupports 212 a, 212 b are adjacent to each other and their groovedsurfaces 216 are aligned such that multiple sutures can be laid across agap 218 between the suture supports. As will be seen below, this willprovide a single cut point to release the valve holder 100 from theprosthetic heart valve 120.

The suture tunnels 214 a and 214 b each have two columns 220 with aninterconnecting span member 222 that together form a tunnel space 224for receiving one or more sutures therethrough. In one embodiment, thereare three support tunnels 214 a, 214 b, 214 c, each located near arespective pair of suture holes 175 a, 175 b, 175 c. Two of the suturetunnels 214 a, 214 b are located on opposite sides of and adjacent torespective suture supports 212 a, 212 b such that the tunnel spaces 224are aligned with the groove surfaces 216 to provide a suture pathwayacross the gap 218. The third suture tunnel 214 c is located next to oneof the tool openings 186 and near the third pair of suture holes 175 c.It will be appreciated that the number and location of suture supportsand suture tunnels for routing and tying down sutures may be varied asdesired. In addition, the columns 220 and span members 222 of the suturetunnels are rounded so as not to chafe or abrade the sutures and toprovide secure surfaces for tying down the sutures. The valve supportbody 110 may be made as a single piece out of a rigid plastic material,or other material suitable to safely secure the prosthetic valve duringshipment and use.

Packaging guides 230 are also provided on the valve support body 110 inorder to secure the valve holder 100 and prosthetic heart valve 120within a package for shipping. In an embodiment of the invention, thepackaging guides are a pair of L-shaped support guides 232 configured toengage packaging components (not shown). A package 60 for the valveholder 110 and prosthetic valve 1 is shown schematically in FIG. 6.

With reference to FIG. 3, the adapter 116 may be employed when thesurgeon prefers to use a handle to insert the prosthetic heart valveinto the native valve annulus. The adapter provides an attachmentmechanism to attach the handle. The adapter may also be used to provideother features, such as suture protection during the implant procedure.The adapter may be made as a single piece out of a rigid plasticmaterial or other suitable material.

With reference to FIGS. 11 and 12, the adapter 116 includes a postmember 240 and a suture shield 242. The post member 240 has at one end afirst cylindrical member 244 that is sized to fit within the cylindricalinner surface 210 of the valve support body 110. The connection may be apress fit, but the connection should not be so tight as to make itdifficult to detach the adapter 116 from the valve support body 110during the surgical procedure.

At the other end of the post member 240 of the adapter 116 is a secondcylindrical member 246 that has a greater outer diameter than the firstcylindrical member 244. Located between the first and second cylindricalmembers is an anti-rotation member 248 having opposed flat sides 250 andopposed curved sides 252. The anti-rotation member is sized to fitwithin the central hole 202 of the valve support body 110 and is sizedto prevent or restrict rotation between the adapter 116 and the valvesupport body 110. On the end of the anti-rotation member 248 adjacentthe first cylindrical member 244, the opposed curved surfaces 252project to form abutments 254 that can engage the shoulders 208 in thecentral hole 202 of the valve support body 110. This prevents theadapter from being inserted too far into the valve support body.

The suture shield 242 extends laterally from the end of the secondcylindrical member 246 adjacent to the anti-rotation member 248. Thesuture shield 242 includes two support arms 280 each having a flatsurface 282 that can bear against the bottom side 200 of the valvesupport body. At the end of each support arm 280, a vertical extensionmember 284 is provided that projects away from the flat surface in thedirection of the second cylindrical member 246. The extension members284 support a suture cover 286 that is arranged to overlap the suturesupports 212 a, 212 b and the suture tunnels 214 a, 214 b. The suturecover 286 prevents the surgeon or clinician from prematurely cutting thesutures to release the valve support body 110 from the prosthetic heartvalve 120. The length and width of the suture cover 286 is preferablysufficient to cover the entire top of each of the suture supports 212 a,212 b and suture tunnels 214 a, 214 b.

The adapter further includes a tab 290 extending laterally in anopposite direction from the suture shield 242. The tab has a flatsurface 292 that, similar to the flat surfaces 282 of the suture shield,can bear against the bottom side 200 of the valve support body 110 toform a firm connection. Suture holes 294 are provided through sutureshield 242 and are aligned with the suture holes 184 of the valvesupport body 110 so that a suture can be tied to secure the adapter 116to the valve support body 110.

With reference to FIG. 13, the post member 240 of the adapter 116 has acentral bore 260 running through the second cylindrical member 246, theanti-rotation member 248 and at least a part of the first cylindricalmember 244. The central bore 260 has an unthreaded portion 262 at theopening to the second cylindrical member 246. Adjacent the unthreadedportion 262 is a threaded portion 264 in the anti-rotation member 248.The first cylindrical member 244 has a reduced sized bore 266 to receivean unthreaded lead-in section 318 of the handle 118. The bore 266 is thesame diameter as or a larger diameter than the lead-in section 318 toprovide clearance.

With reference to FIG. 3, the handle 118 has a bendable portion 310 topermit the handle to be bent in order to access the surgical site fromdifferent directions and angles. The bendable portion 310 is secured toa rigid portion 312 that includes an unthreaded portion 314 and athreaded portion 316 closer to a tip 318 of the handle than theunthreaded portion. In an embodiment, the outer diameter of a thread 320of the threaded portion 316 is the same as the outer diameter of theunthreaded portion 314, although the diameter may be different in otherembodiments. The outer diameter of the thread 320 is the same as theinner diameter of the unthreaded portion 262 of the central bore 260 ofthe adapter 116. The length of the unthreaded portion 262 is severalmillimeters before the start of the threaded portion 204 of the centralbore 260. The unthreaded portion 262 helps insure axial alignmentbetween the threads of the adapter and the handle to preventcross-threading.

Assembly of the prosthetic heart valve holder system of the embodimentof FIGS. 1-13 proceeds as follows. With reference to FIG. 3, one end ofthe central post 114 is inserted into the bore 142 of the deflector 112and the other end of the post is inserted into the bore 180 of the valvesupport body 110. As mentioned earlier, the attachment of the centralpost to the deflector and the valve support body may be by press fit orovermolding, or any other method, such as a snap fit, that prevents theparts from being detached during the surgical procedure.

The assembled valve support body 110 and deflector 112 are then attachedto the prosthetic heart valve 1 (see FIGS. 2 and 4). This may be done byinserting the deflector 112 into the inflow end of the prosthetic heartvalve 1. During the process the arms 132 of the deflector will engagethe leaflets 2 and bend or fold inward toward the central post while theleaflets are moved out of the way to permit the deflector to passthrough the leaflets to the outflow end of the prosthetic valve. Thedeflector 112 is pushed through the valve until the suture ring 5 of theheart valve engages the annular base surface 174 of the valve supportbody 110 (see assembled valve holder 100 and prosthetic valve 1 in FIG.6).

After the suture ring 5 is mounted on the annular base surface 174, theheart valve is rotated on the base surface in order to align the threepairs of suture holes 175 a, 175 b, 175 c of the valve support body withtheir respective commissure posts 4 of the prosthetic valve.Simultaneously, the deflector arms 132 are aligned with respective tips6 of the commissure posts 4.

The deflector arms 132 are arranged over the commissure posts 4 suchthat the tips 6 enter the channels 156 at the outer end portion of eacharm. Preferably, the end wall 152 of the deflector arm is wider than thewidth of the tip and the side flanges 154 cover a portion of the sidesof the tip. The angle that the deflector arms 132 form with the centralpost 114 when mounted to the tips 6 of the commissure post is sufficientto result in the tent-like or umbrella shape, preferably about 25 to 60°such that the ends of the deflector arms attached to the commissureposts are located axially between the central hub 130 and the valvesupport body 110. In addition, the deflector arms are held taut by thecommissure posts 4 causing the deflector to assume an angled tent-likeor umbrella shape.

Sutures 11 are used to attach the prosthetic valve to the support body110 and the arms 132 of the deflector. With reference to FIG. 14, suture11 c is passed through one of the pair of suture holes 175 c. The end ofthe suture 11 c is knotted (at x) to prevent it from passing through thehole. Suture 11 c is passed through the suture ring 5 and along thecommissure post 4 to a location near the tip 6 (not shown). The suture11 c is threaded out of the commissure post and through one of the pairof suture holes 158 of the deflector arm to the outside of the end wall152 and is threaded back to the tip of the commissure post through theother one of the pair of suture holes 158 and threaded back down thecommissure post through the suture ring 5 and through the other one ofthe pair of suture holes 175 c. Suture 11 c is threaded through suturetunnel 214 c, through suture tunnel 214 a, over both suture supports 212a, 212 b and tied down to suture tunnel 214 b.

Sutures 11 a and 11 b are similarly passed through respective pairs ofsuture holes 175 a, 175 b, through the suture ring 5, up respectivecommissure posts 4 to the tips 6, routed out and in through respectiveholes 158 of the deflector arms 132 (see FIG. 6), into the tips 6 andback down the commissure posts 4 through the suture ring 5 and throughthe adjacent hole of the respective pair of suture holes 175 a, 175 b.Each suture 11 a and 11 b is passed through a suture tunnel 214 a, 214 bover both suture supports 212 a, 212 b and tied down to the other suturetunnel 214 a, 214 b. In this way, all three sutures 11 a, 11 b, 11 c arearranged across the gap 218 between the two suture supports 212 a, 212 bto provide a single cut point at the completion of the surgery torelease the valve holder 100 from the prosthetic valve 1.

The suture 11 a, 11 b, and 11 c also hold the deflector arms 132 tautagainst the commissure posts 4. This results in the arms 132 assuming atent-like or umbrella shape that will cause the pre-installed sutures toslide or glide off the umbrella during valve placement and therebypreventing suture looping.

When a handle for the holder is desired (see FIG. 3), the adapter 116 isattached to the valve support body 110 by inserting the post member 240of the adapter 116 into the central hole 202 of the valve support body110 (see FIG. 10). In particular, the post member 248 is inserted untilthe first cylindrical member 244 and the anti-rotation member 248 of thepost member are fully inserted into the central hole of the valvesupport body 110. Preferably, the flat surfaces 282 of the suture shield242 and the flat surface 292 of the tab 290 abut the bottom side 200 ofthe valve support body 110. Finally, a suture 12 is threaded throughsuture holes 294 of the suture shield and suture holes 184 in thesupport body 110 to secure the adapter 116 to the support body (see FIG.3).

The handle 118 is attached to the adapter 116 by guiding the threadedportion 316 of the handle into the central bore 260 of the adapter 116.The unthreaded portion 262 of the central bore (see FIG. 5) will act asa guide to axially align the handle 118 and the central bore 260 of theadapter to permit the handle to be screwed in without cross-threading.

During the surgical procedure, the handle 118 may be used to guide theprosthetic heart valve holder system to the native valve annulus.Examples of such a procedure for installing a new mitral valve isdescribed in U.S. Patent Application Publication No. 2002/0013621, andU.S. Pat. No. 6,966,925, both incorporated herein by reference.

In order to secure the prosthetic valve to the native valve annulus, aplurality of sutures can be pre-installed within the mitral valveannulus. The sutures are then brought outside the body and passedthrough the suture ring 5 of the prosthetic valve 1 of the presentinvention. The handle 118 is then used to guide the valve holder 100 andprosthetic valve 1 along the pre-installed sutures to the native valveannulus.

During delivery of the valve, the pre-deployed deflector 112, with itsumbrella shape, prevents entanglement of the commissure posts with thearray of preinstalled sutures. Once the valve engages the native valveannulus, the handle can be removed by a single cut of suture 12 thatsecures the adapter 116 to the valve support body 110 and the adapter ispulled out of the central hole 202 of the valve support body 110. At thesame time, the suture shield 242 of the adapter is also removed,exposing the sutures 11 a, 11 b, 11 c that are arranged across gap 218(see FIG. 14).

The pre-installed sutures may now be tied off to secure the prostheticvalve to the native valve annulus. Once completed, a member of thesurgical team can make a single cut across the gap 218 to cut all threesutures 11 a, 11 b, 11 c. The valve holder 100 can then be grasped witha tool, e.g., along the rib 188 between the tool openings 186 (see FIG.5), and pulled away from the prosthetic valve. With reference to FIG.15, as the valve holder is pulled from the prosthetic valve, thecollapsible arms 132 of the deflector 112 invert, or fold backward, orflexibly bend, when being pulled through the leaflets 2 and the contactis soft enough to cause no damage to the prosthetic valve or leaflets.In this collapsed position, the central hub 130 is located axiallybetween the free ends of the deflector arms 132 and the valve supportbody 110.

With reference to FIG. 16, another embodiment of a deflector 410 mountedto a prosthetic heart valve 400 includes a central hub 412 and threegenerally radially extending arms 414. The deflector is a monolithicbody made of a material, such as a soft silicone rubber or flexiblepolymer, which permits the arms to bend up and down.

A first end 416 of each arm is attached to the central hub 412 and eacharm extends radially from the central hub to a free end 418. The armsare thin for most of their length, then gradually widen at their freeends to form attachment portions 420. A pair of suture holes 422 areformed through each attachment portion. Sutures may be used to attachthe arms to the tips of the commissure posts 402 of the valve 400 as inthe first embodiment. It will be appreciated that the deflector 410 maybe substituted for the deflector 112 of the first embodiment, or otherdeflectors described in this application.

With reference to FIG. 17, in another embodiment, the central hub 412 ofdeflector 410 is tubular to form a central post 430 extending downtoward the inflow end of the valve 400. A hole 432 passes through thecentral post toward the inflow end of the valve. In an alternativeembodiment, a suture 440 may be routed up through the post 430 andradially along an arm 414 to a first of the pair of suture holes 422,then passed through the first hole and into the tip of the commissurepost 402. The suture is passed back out of the tip and through thesecond hole of the pair of suture holes 422, along the arm radiallyinward to the hub 412 and routed back down the hole 432 to be attachedon the inflow side of the valve. For example, the sutures 440 may passthrough an opening or one of several openings in the conical member 178or at a cylindrical base 190 next to the conical member (see FIG. 9).One end of the suture 440 may then be routed through the sewing ring 5of the prosthetic valve and knotted at one of the pair of suture holes175 a in the support body 110 of the first embodiment. The other end ofthe suture 440 may be routed through the sewing ring 5, and through theother one of the pair of suture holes 175 a, and routed through thesuture tunnels 214 a, 214 b, 214 c and the suture supports 212 a, 212 bas desired. Additional sutures are routed in a similar manner to theother two commissure posts 402.

FIG. 17 shows the deflector 410 in a tented shape with the arms 414 bentat each of their ends near the central hub 412 and near the suture holes422. The arms may also bend anywhere between the ends. FIG. 18 shows thedeflector 410 in a partially collapsed shape wherein the central hub 412is located axially below the free ends 418 of the deflector arms 414.The valve leaflets are removed in FIG. 18 to better view the otherparts.

With reference to FIG. 19 another embodiment of a deflector 500 has aliving hinge 510. The deflector has a central hub 502 and threegenerally radially extending arms 504. Each arm has a concavely curvednotch 506 extending transversely fully across a bottom side of the armto form the living hinge 510. A cornered recess 508 may also be formedin a top side of each arm, directly above the notch 506, leaving a thinrib 512 where bending or folding of each arm can occur. Alternatively,the concavely curved notch can be on the top side and the corneredrecess can be on the bottom side, or only one side can have a notch orrecess, or both sides can have notches or recesses.

In some situations, it may be desirable to move the deflector from anuntented position to a tented position while attached to the prostheticvalve. With reference to FIG. 20, the central post 430 of the deflectoris secured to a handle adapter 444 (shown schematically). Such anadapter 444 may form part of a valve holder (not shown), such asdescribed in U.S. Pat. No. 6,966,925, incorporated by reference herein,to permit movement and locking of the post and deflector 430 relative tothe prosthetic valve 400. With reference to FIG. 21, in anotherembodiment, the prosthetic valve is mounted to a ring 450. The ring maybe used for suture attachment for sutures routed through the centralpost 430 and/or the adapter 444.

It will be appreciated that several ways of routing sutures between theprosthetic valve 1 and the valve holder 100 are described herein forinsuring that those sutures are removed together with the valve holderafter the prosthetic valve is delivered to the native valve annulus andthat suture routing for one embodiment may be used in other embodiments.

In other alternative embodiments, various different features from thedifferent embodiments discussed above can also be combined into a singlemodified valve holder. In addition, various other modifications oralternative configurations can also be made to the valve holderaccording to the above described embodiments of the invention.

For purposes of this description, certain aspects, advantages, and novelfeatures of the embodiments of this disclosure are described herein. Thedisclosed methods, apparatus, and systems should not be construed asbeing limiting in any way. Instead, the present disclosure is directedtoward all novel and nonobvious features and aspects of the variousdisclosed embodiments, alone and in various combinations andsub-combinations with one another. The methods, apparatus, and systemsare not limited to any specific aspect or feature or combinationthereof, nor do the disclosed embodiments require that any one or morespecific advantages be present or problems be solved.

Although the operations of some of the disclosed embodiments aredescribed in a particular, sequential order for convenient presentation,it should be understood that this manner of description encompassesrearrangement, unless a particular ordering is required by specificlanguage set forth below. For example, operations described sequentiallycan in some cases be rearranged or performed concurrently. Moreover, forthe sake of simplicity, the attached figures may not show the variousways in which the disclosed methods can be used in conjunction withother methods. Additionally, the description sometimes uses terms like“provide” or “achieve” to describe the disclosed methods. These termsare high-level abstractions of the actual operations that are performed.The actual operations that correspond to these terms can vary dependingon the particular implementation and are readily discernible by one ofordinary skill in the art.

In view of the many possible embodiments to which the principles of thedisclosure can be applied, it should be recognized that the illustratedembodiments are only preferred examples and should not be taken aslimiting the scope of the disclosure. Rather, the scope of thedisclosure is defined by the following claims.

What is claimed is:
 1. A prosthetic heart valve holder comprising: adeflector having a hub and a plurality of arms extending radiallyoutwardly from the hub, each of the arms having a first end connected tothe hub and a free second end positioned radially outwardly from thehub; a valve support body; and a post extending between and connectingthe valve support body and the hub, wherein an outer width of the hub isgreater than an outer width of the post; wherein the arms aredeflectable axially relative to the hub, such that in a firstconfiguration the second ends of the arms are positioned closer axiallyto the valve support body than the hub is to the valve support body, andin a second configuration the second ends of the arms are positionedfarther away axially from the valve support body than the hub is to thevalve support body.
 2. The prosthetic heart valve holder of claim 1,wherein the deflector comprises at least three arms.
 3. The prostheticheart valve holder of claim 1, wherein an end of the post is insertableinto the hub of the deflector.
 4. The prosthetic heart valve holder ofclaim 1, wherein the post comprises a solid pin.
 5. The prosthetic heartvalve holder of claim 1, wherein the post is molded or press-fit to thehub of the deflector.
 6. The prosthetic heart valve holder of claim 1,wherein an axial distance between the hub of the deflector and the valvesupport body remains fixed.
 7. The prosthetic heart valve holder ofclaim 1, further comprising an adaptor that is detachably connectable toa side of the valve support body opposite the post and the deflector,wherein the adaptor comprises a suture shield for covering sutures whichconnect a prosthetic heart valve to the prosthetic heart valve holder.8. The prosthetic heart valve holder of claim 1, further comprising ahandle that is detachably connectable to a side of the valve supportbody opposite the post.
 9. A prosthetic heart valve holder comprising: adeflector having a hub and a plurality of arms extending radiallyoutwardly from the hub, each of the arms having a first end connected tothe hub and a free second end positioned radially outwardly from thehub; a valve support body; and a post extending between and connectingthe valve support body and the hub, wherein each of the arms remainsentirely spaced apart from the post; wherein the arms are deflectableaxially relative to the hub, such that in a first configuration thesecond ends of the arms are positioned closer axially to the valvesupport body than the hub is to the valve support body, and in a secondconfiguration the second ends of the arms are positioned farther awayaxially from the valve support body than the hub is to the valve supportbody.
 10. The prosthetic heart valve holder of claim 9, wherein thedeflector comprises at least three arms.
 11. The prosthetic heart valveholder of claim 9, wherein the hub is positioned between the post andeach of the arms and prevents the arms from contacting the post.
 12. Theprosthetic heart valve holder of claim 9, wherein each of the armsdefines a transversely extending notch that forms a living hinge. 13.The prosthetic heart valve holder of claim 9, wherein the post comprisesa solid pin.
 14. The prosthetic heart valve holder of claim 9, whereinthe post is molded or press-fit to the hub of the deflector.
 15. Theprosthetic heart valve holder of claim 9, wherein an axial distancebetween the hub of the deflector and the valve support body remainsfixed.
 16. The prosthetic heart valve holder of claim 9, furthercomprising an adaptor that is detachably connectable to a side of thevalve support body opposite the post and the deflector, wherein theadaptor comprises a suture shield for covering sutures which connect aprosthetic heart valve to the prosthetic heart valve holder.
 17. Theprosthetic heart valve holder of claim 9, further comprising a handlethat is detachably connectable to a side of the valve support bodyopposite the post.
 18. A prosthetic heart valve holder comprising: adeflector having a hub and a plurality of arms extending radiallyoutwardly from the hub, each of the arms having a first end connected tothe hub and a free second end positioned radially outwardly from thehub; a valve support body; and a post extending between and connectingthe valve support body and the hub; wherein the arms are deformableaxially relative to the hub, such that in a first configuration thesecond ends of the arms are positioned closer axially to the valvesupport body than the hub is to the valve support body, and in a secondconfiguration the second ends of the arms are positioned farther awayaxially from the valve support body than the hub is to the valve supportbody.
 19. The prosthetic heart valve holder of claim 18, wherein thearms of the deflector comprise a material with a durometer in the rangeof shore A30 to shore A70.
 20. The prosthetic heart valve holder ofclaim 18, wherein each of the arms defines a transversely extendingnotch that forms a living hinge.